Refill Medications

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    By using this form, you are able to re-fill your prescriptions over the Internet.  It's easy, just fill out the form below, click on the "Submit" button, and your order will be sent to us.  We will then check to make sure that you are able to have the re-fill at this time; we will then call you and tell you when the re-fill is ready for you to pick up or when you want us to deliver the order.

    There are a few guidelines, however, that must be followed: 

  1. You  must fill out ALL of the demographics part of the form below in order to handle your prescription over the Internet. 

  2. The original prescription MUST have been filled previously by one of our stores. 

  3. There must be no changes from the original prescription that is on file.

  4. If you only need one or two drugs, just fill in the information for the one or two drugs, then skip down to the  "Submit"  button and click on it.

 Click here If you want to go back to the Home Page. 

    The top part (Demographics) of following form must be completely filled out with your name address, phone number etc. in order to have your drugs refilled over the Internet.

    If the following Demographics are already on file with us, answer the first question by answering "Yes."  Then the only ones that need to be entered are the ones below that are highlighted.  (Use the "TAB" key to jump from block to block.)

Demographics

    My Demographics are already on file in your office      YES        NO     (Required)

I will pick up my Medicine        I want my Medicine delivered    (Required)

Last Name:  First Name:        Middle Initial : 

Address:      May NOT be a Post Office Box

City:                State:    Zip: 

    At least one telephone number is required.  One telephone number is needed so that we may contact you if needed.

Home Phone Number:       (Where we may contact you if needed)

Business Phone Number:  (Where we may contact you if needed)         

My E-mail address is        

Comments:

    If the part of the form just above is not completely filled out,  we will be unable to honor this request and there will be no drug re-fill over the Internet.

            Prescriptions to be refilled         

Physician Drug Name Dose How Taken Last Refill Rx Number
(optional)		 Filled at Vista or
Professional
Pharmacy
Vista Pro
Vista Pro
Vista Pro
Vista Pro
Vista Pro
Vista Pro
Vista Pro
Vista Pro
Vista Pro
Vista Pro

Click here to go to the TOP of this form to re-check what you have written

   If you have questions, contact us Click here to Email any questions you may have

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Winton's Professional Pharmacy  |  Vista Pharmacy
Date this page was last updated  02/17/2005